Virtual advantage: Advancing new nurse readiness and confidence in complex medical environmentsKandi Helminiak, RN, BSNClinical Nurse ExecutiveElsevier

Nurse residency programs are a frequent focus in today’s complex healthcare environment as hospitals and health systems seek to accelerate new nurse readiness, strengthen engagement and support, and reduce turnover rates. Complicating these efforts is an uncertainty permeating the nursing profession—and healthcare as a whole—during a global pandemic that has new nurses in particular struggling to effectively transition into the workforce.

Nurse residency programs have become a focal point of nurse retention strategies in part due to the alarming statistics associated with turnover rates. Nationally, an average of one in five nurses will leave their first job within 12 months, contributing to an annual loss of up to $7 million per hospital.i The cost to replace each of those nurses is unsustainable, with onboarding alone carrying a price tag of $32,000-67,000 per each new nurse. ii

Contributing factors The search for a solution to high turnover rates is not new. In fact, creating a Transition to Practice Program to enhanced retention was one of the recommendations set forth by the Institute of Medicine (now known as the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine) in The Future of Nursing: Leading Change, Advancing Health. iii Though many of the recommendations in that report have been delayed due to the COVID-19 pandemic, ample data exists to support their effectiveness, with most healthcare organizations already having established nurse residency programs. Adding to the urgency for a solution is the looming retirement of a sizable number of experienced, tenured nurses by 2025. Data suggests that while 2 million new nurses will join the workforce by then, another 1 million will be lost. Further, a recent study by the National Bureau of Economic Research revealed a drop of about 7% in labor force participation—which is more than twice the cumulative drop in the eight years from 2008-2016—and a 7% increase in individuals identifying as retiring. iv Also at play is a sense of uncertainty plaguing nurses who are providing patient care through the pandemic, which is driven in large part by the “insufficient resource trauma” nurses are experiencing on the job. That is according to an American Nurses Association survey which found that 87% of participating nurses indicated they were afraid to go to work because of COVID-19. Another 68% were worried about their organizations being short-staffed and 36% felt that they took care of infectious patients without adequate personal protective equipment (PPE). Just 11% felt that they were well prepared to take care of COVID-19 patients.v Finally, a growing number of nurses have indicated that they are leaving patient care—taking with them years of knowledge and experience—out of fear they could infect their families and loved ones if they continue to work with COVID-19 patients.vi It is a grim reality made bleaker by the ongoing nursing shortage that makes replacing them a daunting prospect.

Adding to the pandemic-driven stress for new nurses is the increasingly complex nature of healthcare. The U.S. population is aging and experiencing higher rates of chronic conditions. Statistically speaking, 4 in 10 U.S. adults currently suffer from two or more chronic conditions.vii Add to that new mandates around quality and safety, increased competition for patient populations, a shift in care delivery, and a shortage of physicians and allied health professionals (in addition to nurses), and it’s easy to understand why stress levels are skyrocketing, especially among new nursing graduates who lack the experience and confidence to fall back on.

Immediate action required While the specific short- and long-term impacts of this tumultuous time in healthcare are yet known, there is no question that it will leave a damaging imprint. Immediate action is needed to find solutions that will not only better prepare new nurses for the realities of practice, but also accelerate the identification of struggling new nurses so that proper steps can be taken to guide them through the issues they are facing.

Leading during any crisis demands strength, perseverance, and direction. Early, frequent intervention reduces stress and, subsequently, the risk of burnout. That translates into an approach that leads with education while also building connections with a team of advocates who can provide new nurses with a safe place to voice anxieties and address concerns.

“ What’s most concerning now are the long-term consequences. It’s not only post-traumatic stress, but this feeling in some people that they’re acting against their own consciences in certain actions during this crisis. We can’t wait to take measures to manage their distress.” – Cynda Rushton, nursing ethics educator

with Johns Hopkins

For new nurses, those concerns can be traced back to five main barriers that can keep them from success in their chosen profession: 1. The reality shock of moving from the classroom to

the professional clinical setting.2. Varying levels of experience due to different nursing

programs, degree levels, and individual learning styles.

3. Personal challenges, such as family issues, childcare, debt, etc.

4. Limited preparedness from decreased clinical hours, a mid-course switch to virtual learning and other educational disruptions.

5. COVID-19 and the environmental changes it causes, including disruptions to professional and personal lives.

Three primary strategies have been identified to overcome these barriers and boost new nurse readiness, all of which can be addressed through enhanced nurse residency programs: leveraging technology to build confidence, strengthening engagement and support, and understanding where and when new nurses are struggling.

Transforming nurse onboarding programs By integrating these strategies into nurse residency or onboarding programs, new nurses can be instilled with greater confidence in their skills and enhance their readiness for clinical practice. Doing so can also ensure access to the support and tools needed to help guide new nurses through challenging times that might otherwise cause them to abandon their chosen profession.

Leveraging technologyThere are three touchpoints when it comes to leveraging technology to build both confidence and competence: use of virtual education for a more tailored experience, constructing a virtual support system for new nurses, and identifying trends and risks at the cohort and individual levels. Virtual education was already making inroads into health education well before the pandemic accelerated the transition. A significant aspect of its appeal is the ability to standardize the orientation process and content across an entire health system, ensuring nurses receive the same training regardless of their location. It also eliminates the need for nurses to travel to a central location for training and is preferred by Millennials who appreciate its self-paced nature.While those practical aspects are important, the true impact of virtual learning comes from its ability to be tailored to the unique needs of both the nurse and facility. Hospitals that have incorporated virtual learning into onboarding and residency programs have found it to be highly effective at delivering standardized education, as well as organizational policies and procedures--all of which can be updated as needed due to changes with medical evidence or regulations. For nurses, virtual learning helps advance clinical and professional skills by providing nurse leaders with information on areas where individual nurses are struggling, which allows them to tailor their support to those individual needs. This includes clinical practice scenarios to close the readiness gaps created by limited exposure to real-world scenarios and hands-on experience. This helps ensure both readiness and clinical confidence in new nurses, which goes a long way toward alleviating the stress caused by insecurities and uncertain times.

Strengthening engagement and supportToo often, hospitals consider surveying new nurses at the start, mid-point, and end of a residency program as sufficient engagement. Unfortunately, this approach fails to inform nurse leaders of ongoing and emerging issues that threaten to derail even the most confident of new nurses. Infrequent communication also contributes to new nurses’ discomfort when providing nurse leaders with candid feedback and risks damaging efforts to build a culture of support. A proper approach to strengthening engagement and support is one that incorporates a regular communication cadence with new nurses. This helps identify barriers and personal struggles for individual intervention as well as broader cohort-level trends that can be addressed by an adjustment in residency program curriculum. Without regular communication, it is impossible to know what struggles new nurses are dealing with that can impact their overall confidence and satisfaction. It goes beyond the challenge inherent in today’s complex healthcare environment to include personal issues—because any struggles they are dealing with off the clock will impact their performance at work. This is especially true during the pandemic, when nurses are dealing with any number of complex personal issues. They may be caring for a sick family member, dealing with the death of a loved one, or struggling with the fear that they may expose an immunocompromised loved one to the COVID-19 virus. Open, direct lines of communication between nurses and their support teams improves practice readiness. Providing a safe place for new nurses to give and receive candid feedback and reflect on their feelings builds their confidence and sense of support. Communication also helps alleviate feelings of abandonment—which are often exacerbated by the inability to form bonds with their peers when education is limited to virtual learning without the option for in-person meetings.

“ Leading during any crisis demands strength, perseverance, and direction. Lead with education while also building connections with a team of advocates to find a safe place for new nurses to voice their anxieties and address concerns. Intervening early and often reduces the risk for burnout.” – Kandi Helminiak, RN, BSN,

Clinical Nurse Executive, Elsevier

Understanding where nurses are strugglingUltimately, what new nurses need most is a team of mentors and advocates who empower them with timely guidance and support tailored to their unique needs. They need a safe space for self-reflection and the opportunity to have concerns addressed at regular intervals during the Transition to Practice Program. Establishing this kind of communication provides leadership with a much clearer picture of how to reinforce individual strengths and shore up weaknesses so new nurses are practice ready and confident in their skills. These insights can then be integrated into a residency program’s virtual curriculum to provide them with actionable insights, professional skills and engagement and support tools that allow new nurses to thrive.

Copyright 2020 Elsevier

Learn more at elsevier.com/transition-to-practice

References i: Thew, J., (2019). “Want to Keep Nurses at the Bedside? Here’s How”. HealthLeaders. ii: Gloss, C., (2015). Systemic review building a preceptor support system. Journal for Nurses Professional Development, 31(1), 7-14. iii: Institute of Medicine. (2011). The future of nursing: Leading change, advancing health.

Washington, DC: The National Academies Press. iv: National Bureau of Economic Research (2020). Early Evidence on the Impact of COVID-19 and the Recession on Older Workers.

Working Paper 27448. v: American Nurses Association (April 24, 2020). Survey: Nurses Fear Going to Work Due to Lack of Protection from Virus

More than 32k Nurses Share Experience from the Front Lines. ANA press release. vi: Helminiak, K. Leading New Nurses Through Uncertainty. HealthLeaders Webinar vii: Chronic Diseases in America. Center for Disease Control and Prevention. April 2019

“ Empower a career grounded in quality practice, evidence, and collaboration for your new graduate nurses.”– Kandi Helminiak, RN, BSN,

Clinical Nurse Executive, Elsevier

A virtual transformation Nurse residency programs can best be accomplished with an immersive, virtual learning experience that delivers the evidence-based curriculum they need to excel while supporting the individual learner needs for stronger engagement. This can be achieved through online, evidence-based content designed to close gaps in essential skills through case-based scenarios that simulate real-life situations and build upon the pillars of communication, collaborative practice, evidence-based practices and research, ethical nursing practice, and leadership. An immersive environment can then be created by offering virtual learning that leverages a combination of modalities including simulation, interactive games, interactive videos, and graphic novels to keep learners engaged while accommodating their unique learning styles.Virtual learning—indeed technology in general—is a highly effective channel for providing engagement and support tools that break down communication barriers, foster candid insights and self-reported feedback, and provide tailored support and timely dialog. Whether it is an end-of-shift survey that alerts nurse managers to an urgent need to intervene with a struggling nurse or a self-reflection journal entry that opens the lines of communication between new nurses and their support teams, engagement and support tools help new nurses develop resiliency and confidence in their abilities.

Finally, virtual training programs can provide leadership with actionable insights by helping to identify trends at the cohort and individual levels and enabling rapid detection of where new nurses are struggling. They can also serve as a way to monitor new nurse confidence and satisfaction levels, allowing for more timely intervention.

By integrating virtual learning into nurse residency and onboarding programs, new nurses are provided with the education, information, and tools to support a career grounded in quality, evidence, and collaboration. It increases their resiliency so they can recover quickly from difficult times, and ultimately enables them to couple the art of caring with scientific knowledge to promote wellness and deliver high-quality care for optimal patient outcomes.